Identifying Legitimate Pain from Addictive Behaviors; How can the physician identify legitimate pain from addictive behaviors?, Should the doctor rely on the patient’s word or should the physician order urine toxicology testing to confirm the presence of prescribed medications?
There is nothing more disheartening and disrupting to a pain practitioner than a drug abuser or addict who manages to gain entry into the practice and subsequently exhibits noticeable addictive or deviant behaviors.1-3 The national drive to eliminate under-treatment of pain and relieve the suffering of thousands of bed and house-bound pain patients has given the abuser and addict an opportunity to enter many new and embryonic pain practices. To date, little was known about the profile of abusers and addicts who prey upon pain practices.4-6 In contrast to the heroin addict who is relatively easy to identify by criminal records, presence of needle marks, and morphine in body fluids, most abusers and addicts who frequent pain practices use oral opioids and may have few obvious characteristics to identify them.5-7 Fortunately, the movement to provide opioid treatment to legitimate, non-abusers in pain has now matured enough to allow profiling of oral, opioid abusers and addicts so that some guidance in spotting these individuals can be provided. To assist in preparation of this article, the authors reviewed twenty patients in their practices who entered pain treatment and later demonstrated deviant, addictive behaviors and had to be forcibly discharged. Identifying Legitimate Pain from Addictive Behaviors
Drug Abuser and Addict Defined
There appears to be a general consensus on definitions utilized in the practice of pain management.8,9 Fundamentally, a legitimate pain patient uses opioids and other medications to relieve pain while abusers and addicts use the drugs for psychologic, ill-defined reasons other than pain relief. Table 1 lists the definitions used by the Federation of State Medical Boards which are similar to those used in a joint consensus statement of the American Pain Society and the American Society of Addiction Medicine.8 Of special significance to pain practitioners is the definition of “pseudo-addict” who is a patient who frequents emergency rooms and multiple physicians to obtain additional pain relief medication, because their primary pain practitioner is under-treating them.